Review Question - QID 103805

This child presents with physical exam findings classic for atopic dermatitis. Topical corticosteroids are first-line treatment for atopic dermatitis flare, with skin atrophy as the most common side effect of prolonged use.

Atopic dermatitis, also known as atopic eczema, is a chronic inflammatory skin condition that presents differently in different age groups. Infants typically present with an erythematous, weeping, pruritic rash on the face, scalp, and diaper areas. Children and adults present with pruritic, erythematous, and scaly lesions often localized to the flexural surfaces of the body. Patients with atopic dermatitis are advised to apply emollients whether or not active symptoms are present. Topical corticosteroids are first-line treatment for atopic dermatitis flare-ups. Local side-effects of topical corticosteroids include skin atrophy, telangiectasia, hypertrichosis, acneiform eruptions and striae.

Ference and Last review the considerations in choosing a topical corticosteroid agent. The most common side effect of topical corticosteroid use is skin atrophy. All topical steroids can induce atrophy, but higher potency steroids, occlusion, thinner skin, and older patient age increase the risk. The face, backs of the hands, and intertriginous areas are particularly susceptible.

Hanifin et al. conducted a study in children and adults with moderate to severe atopic dermatitis to determine a strategy for long-term control and management. Though topical corticosteroids are the mainstay of treatment in atopic dermatitis flares, there is no standard treatment plan for chronic management of the disease. The study found that the risk of relapse of atopic dermatitis can be significantly reduced by extended intermittent dosing with topical corticosteroid in addition to regular emollient therapy.

Illustration A demonstrates a classic presentation of atopic dermatitis in an infant. Note an erythematous, weeping rash distributed on this child's cheeks bilaterally.

Illustration B demonstrates a more common presentation of atopic dermatitis in children and adults. Note the scaly, excoriated lesions on this patient's flexural region.

Incorrect answers:
Answer 1: Hypopigmentation, not hyperpigmentation, is classically seen with prolonged topical steroid use.
Answer 3: Paresthesia is a common side effect of topical calcineurin inhibitors, such as tacrolimus, which are second-line therapy for atopic dermatitis. They are generally reserved for short-term therapy in persons with moderate to severe atopic dermatitis.
Answer 4: Increased risk for melanoma and squamous cell carcinoma is a concern in the use of ultraviolet light therapy for recalcitrant atopic dermatitis.
Answer 5: Hypoglycemia is not a common concern with topical corticosteroid therapy. Topically applied high-potency corticosteroids can be absorbed well enough to cause systemic side effects, such as hypothalamic-pituitary-adrenal suppression, hyperglycemia, and hypertension.